Basic Information
Provider Information | |||||||||
NPI: | 1790448389 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRINE HEALTH MEDICAL GROUP, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 370 OLD COUNTRY RD STE 100 | ||||||||
Address2: |   | ||||||||
City: | GARDEN CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 115301702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5163655570 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1129 NORTHERN BLVD STE 101 | ||||||||
Address2: |   | ||||||||
City: | MANHASSET | ||||||||
State: | NY | ||||||||
PostalCode: | 110303022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5163655570 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2021 | ||||||||
LastUpdateDate: | 10/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAYNES | ||||||||
AuthorizedOfficialFirstName: | GEORGIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 5164072731 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.